UvA-DARE (Digital Academic Repository) Gastrointestinal consequences of bariatric surgery Boerlage, T.C.C. Link to publication Citation for published version (APA): Boerlage, T. C. C. (2018). Gastrointestinal consequences of bariatric surgery: The Roux-en-Y gastric bypass unveiled General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: http://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl) Download date: 15 Mar 2019
GASTROINTESTINAL CONSEQUENCES OF BARIATRIC SURGERY Thomas Boerlage GASTROINTESTINAL CONSEQUENCES OF BARIATRIC SURGERY The Roux-en-Y gastric bypass unveiled Thomas Boerlage
GASTROINTESTINAL CONSEQUENCES OF BARIATRIC SURGERY The Roux-en-Y gastric bypass unveiled THOMAS BOERLAGE Als ik later groot ben, word ik ook expert opinion
Gastrointestinal consequences of bariatric surgery: The Roux-en-Y gastric bypass unveiled Academic thesis, University of Amsterdam Thomas C.C. Boerlage Copyright 2018 TCC Boerlage, Amsterdam, the Netherlands No part of this thesis may be reproduced, stored in an electronic database, or published in any form or by any means, without written permission of the author or the publisher holding copyright. Layout: Thomas Boerlage & Anna-Linda Peters Cover design: Bregje, proefschriftontwerp.nl Printed by: Ipskamp printing The printing of this thesis was financially supported by: Stichting Klinisch Wetenschappelijk Onderzoek Slotervaartziekenhuis (SKWOSZ), Academisch Medisch Centrum, Chipsoft, Zambon BV
GASTROINTESTINAL CONSEQUENCES OF BARIATRIC SURGERY The Roux-en-Y gastric bypass unveiled ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus prof. dr. ir. K.I.J. Maex ten overstaan van een door het College voor Promoties ingestelde commissie, in het openbaar te verdedigen in de Agnietenkapel op donderdag 1 november 2018, te 14:00 uur door Thomas Cornelis Constantijn Boerlage geboren te Purmerend
Promotiecommissie: Promotores: Prof. dr. P. Fockens Universiteit van Amsterdam Prof. dr. D.P.M. Brandjes Universiteit van Amsterdam Copromotores: Dr. V.E.A. Gerdes MC Slotervaart Dr. R.P. Voermans Universiteit van Amsterdam Overige leden: Prof. dr. E.M.H. Mathus-Vliegen Universiteit van Amsterdam Prof. dr. M. Nieuwdorp Universiteit van Amsterdam Prof. dr. A.K. Groen Universiteit van Amsterdam Prof. dr. F.P. Vleggaar Universiteit Utrecht Prof. dr. N.D. Bouvy Universiteit Maastricht Dr. L.M. de Brauw MC Slotervaart Faculteit der Geneeskunde
Table of contents Outline of this thesis 9 Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Bariatric surgery: who, when and where? An overview for the physician. Nederlands Tijdschrift voor Geneeskunde 2017 Gastrointestinal symptoms and food intolerance 2 years after laparoscopic Roux-en-Y gastric bypass for morbid obesity. British Journal of Surgery 2017 Longitudinal assessment of gastrointestinal symptoms after laparoscopic Roux-en-Y gastric bypass. Submitted Proton pump inhibitor prophylaxis after gastric bypass does not cause hypomagnesaemia. Obesity Surgery 2016 Faecal calprotectin, elastase and alpha-1-antitrypsin levels after Roux-en-Y gastric bypass; calprotectin is significantly elevated in the majority of patients. Obesity Surgery 2016 Upper endoscopy after Roux-en-Y gastric bypass: diagnostic yield and factors associated with relevant findings. Submitted A novel fully covered double-bump stent for anastomotic leaks after bariatric surgery: a retrospective analysis. Surgical Endoscopy 2018 Ursodeoxycholic acid for the prevention of symptomatic gallstone disease after bariatric surgery: study protocol for a randomized controlled trial (UPGRADE trial). BMC Gastroenterology 2017 13 27 47 63 71 87 109 125 Chapter 9 Summary & General discussion (in English) 143 Chapter 10 Samenvatting voor niet-medici (in het Nederlands) 165 Publications included in this thesis with authors contributions 173 Portfolio & Curriculum Vitae 177 Dankwoord 183 7
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OUTLINE OF THIS THESIS 9
Bariatric surgery is the generic term for all types of surgery for the treatment of morbid obesity (ancient Greek: - weight and - doctor). The most commonly performed bariatric procedure is the Roux-en-Y gastric bypass (RYGB), the primary topic of this thesis. In Chapter 1, we give a general overview of bariatric surgery, its effects and its complications. In the following chapters the main emphasis is on the postoperative gastrointestinal consequences. In Chapter 2 we study the gastrointestinal symptoms and food intolerance of patients who underwent RYGB two years before. Patients with morbid obesity have more gastrointestinal complaints than normal-weight controls. Therefore, it might be hypothesized that the weight loss after RYGB also leads to a decrease in gastrointestinal symptoms. On the other hand, RYGB is known to sometimes aggravate certain symptoms, for example dysphagia. RYGB also has a strong impact on food tolerance, with many patients developing food intolerance after surgery. Studies with followup extending beyond the first year after surgery are scarce, even though it is only in the second year postoperative that the weight loss and eating behavior stabilizes. Therefore, this study was designed to determine the gastrointestinal symptoms and food intolerance in patients two years after RYGB and compare these to an obese control group. The majority of the patients in this control group eventually underwent RYGB as well. In Chapter 3 we study the gastrointestinal complaints of these patients two years after surgery as well. Because of the longitudinal design of this study, we are also able to study the course of gastrointestinal symptoms in time. We can also determine whether patient characteristics, such as preoperative symptoms and prolonged use of medication with abdominal effects such as proton pump inhibitors, can be predictive of the severity of postoperative gastrointestinal symptoms. Considering the routine use of a proton pump inhibitor after RYGB, we study the prevalence of hypomagnesaemia in Chapter 4. Hypomagnesaemia is a rare but sometimes severe complication of proton pump inhibitors. We will determine the prevalence of hypomagnesaemia in the first year of RYGB in a large group of patients, who were routinely prescribed a proton pump inhibitor in the first year after surgery. When a bariatric patient presents with gastrointestinal complaints, it is often difficult for the clinician to distinguish between symptoms indicative of pathology, and functional complaints that need no further evaluation. In Chapter 5 we study three commonly used faecal tests in patients who underwent RYGB. Because RYGB causes 10
alterations in gastrointestinal anatomy and function, we hypothesize that the levels of these faecal markers might also change. The faecal calprotectin level can be used for the diagnosis or follow-up of inflammatory bowel disease; faecal elastase gives an indication of pancreatic exocrine function; and faecal alpha-1-antitrypsin is a marker for intestinal leakage of protein. In Chapter 6 we study the diagnostic yield of upper endoscopy in patients who underwent RYGB and present with abdominal complaints. An upper endoscopy is frequently performed after RYGB, but often no abnormalities are found. We determine the prevalence of relevant findings at upper endoscopy, such as marginal ulcer and stomal stenosis, in our centre. Next, we aim to identify variables associated with a relevant finding at EGD, and create a prediction model. In Chapter 7 we study endoscopic stent placement in patients with staple line leakage after RYGB or sleeve gastrectomy. Staple line leakage is a severe adverse event of bariatric surgery for which revisional surgery is often necessary. In selected cases, endoscopic placement of a self-expandable stent can be an alternative to surgery. However, stents often migrate, hampering successful treatment or even leading to serious complications. The design of the Beta stent is thought to prevent migration; in this chapter we evaluate the success percentage and complication rate of this specific stent. Another complication of bariatric surgery is symptomatic gallstone disease. The rapid weight loss after surgery greatly increases the chance of developing gallstones. However, routine concurrent cholecystectomy was found not to be effective when it comes to costs and comorbidity. Ursodeoxycholic acid was shown to be effective in the prevention of gallstone development, but no studies have been performed with symptomatic gallstone disease as an endpoint. In Chapter 8 we describe the protocol for the UPGRADE, a randomized controlled trial that is currently underway. Finally, in the Summary & General Discussion we will discuss the results of the previous chapters and share our thoughts on their implications and on the future developments in bariatric surgery. 11